A nurse in the emergency department is receiving report on a group of clients. Which of the following clients should the nurse assess first?
A client who has Clostridium difficile and a temperature of 38.6° C (101.5° F)
A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10
A client who has left shoulder pain and S-T elevation on a 12-lead ECG
A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities
The Correct Answer is C
A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. For clients receiving hemodialysis, maintaining adequate protein intake is essential because dialysis can remove protein from the blood. The recommended intake is typically about 1 g/kg/day, which helps replace losses and supports overall health.
B. Consume foods high in potassium. Clients with chronic kidney disease often need to restrict potassium intake due to impaired kidney function and the risk of hyperkalemia.
C. Take magnesium hydroxide for indigestion. Clients with chronic kidney disease should avoid magnesium-containing antacids due to the risk of magnesium accumulation and toxicity.
D. Drink at least 3 L of fluid daily. Fluid intake usually needs to be restricted in clients undergoing hemodialysis because their kidneys cannot effectively remove excess fluid, which can lead to complications like hypertension and pulmonary edema.
Correct Answer is C
Explanation
A. Borderline personality disorder is characterized more by unstable and intense interpersonal relationships rather than clinginess.
B. While some individuals with borderline personality disorder may exhibit manipulative behaviors, this does not universally manifest as seductiveness.
C. Impulsivity, such as reckless spending or substance abuse, is a hallmark feature of borderline personality disorder, making it a crucial aspect to include in education about the condition.
D. Borderline personality disorder is not typically associated with excessive concern about minor details; instead, it's marked by a pattern of instability in mood, self- image, and behavior.
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